Requestfor Mediation

							                                                      IN THE CIRCUIT COURT OF THE
                                                      NINTH JUDICIAL CIRCUIT IN AND
                                                      FOR ORANGE COUNTY, FLORIDA

                                                      CASE NO: DR______________
                                                      DIVISION _____
______________________
      Petitioner,

and

______________________
      Respondent.
______________________/

                                 REQUEST TO SET MEDIATION

      I hereby request that a mediation on the above-styled cause for the following reason:
      ______ pursuant to my agreement/Final Judgment (attached hereto) that we mediate disputes
      prior to filing another action. The issues to be mediated are:
_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

        I hereby certify that a copy of this motion has been hand delivered/mailed to:
________________ at the following address:_________________________________
______________________________, whose phone number is ___________________
this _______ day of ________________, 20___.
                                                          ________________________
                                                          Signature
                                                          ________________________
                                                          Address
                                                          ________________________
                                                          City, State, Zip
                                                          ________________________
                                                          Phone Number


                                              ORDER


       The court hereby grants/denies the Motion to Set Mediation.


                                                      _____________________________
                                                      Circuit Judge
                                                      _______________________
                                                         Date
      Copies to Mediation and ____________________________________________________


on __________________,_________ __________________,    Judicial Assistant